CODE BROWN: AHHH…THE OLD SCANCRIT SWITCHEROO…

Someone once said that ‘an esophageal intubation is no sin, but there is great sin in not recognizing such a placement‘.

What’s that about?

I intentionally intubate the esophagus and I demand recognition for it.

This is our latest attempt at the eponymous naming of a controversial procedure that is not based on any evidence whatsoever.

The situation
Some time ago we we called to the cath lab where a patient had arrested during PCI. As we arrived compressions were ongoing as the cardiologist desperately tried to open the left coronary. The patient was very obese with a short neck. As we entered the room we could see how his mouth and reservoir mask started filling up with gastric contents. The intubation was a nightmare from the start. A tidal wave of vomit steadily kept welling up into the mouth and upper airway. Suctioning did not help as the mouth kept filling up as soon as we removed the yankauer catheter and tried to intubate. The suction device also clogged several times.

After two gnarly attempts at intubation we gave up. Decision time. The nurse anesthetist ran to get the ILMA for a blind intubation. There wouldn’t be time for that. The next algorithm step would be a surgical airway which, given the layers of fat over the patient’s short neck, would be a complete nightmare. Inserting a LMA was an option but as the patient had arrested with a massive pulmonary oedema it really wasn´t what we wanted. We made a third and final attempt at intubating the patient.

The solution
Instead of attempting a blind intubation we shoved the ETT well down the esophagus and inflated the balloon cuff with a 20ml syringe.

The steady flow of vomit immediately stopped and was instead funnelled through the esophageal ETT and drained in copious volumes outside the airway. We could now efficiently suction and clear the mouth of gastric contents.

The glottis became, and remained, visible. I was given the spare ETT loaded on a bougie. With some minor manipulation the patient was easily intubated despite a CL grade 3 view. This whole manoeuvre took less than 30 seconds from esophageal blocking to getting the first capnograph trace.

Take-home message
I discussed the case with a senior colleague of mine. She is an amazing anaesthetist and our favourite consultant. She is also brutally, scary, honest.

First, she suggested that I accidentally intubated the esophagus and had retconned my story in order to look clever. I assured her that was not the case. Then she criticised me ignoring all known emergency airway algorithms. Basically she called me a liar and/or an idiot!

Update: We published these findings – and lo and behold: someone else did too, at the same time. Anyway, now there are two papers out, sort of confirming this might be a decent idea in certain settings.

The clinical scenario you describe here defies an algorithm–you are not an idiot.
You are obviously not a liar.
The vomit needed a natural path out of the body, away from the airway, and out of your working space to resuscitate the patient. You figured it out logically.
Your approach to this case has been discussed over the years (deliberate insertion of a tracheal tube in the esophagus), but has never been codified in an algorithm, other than serving as the inspiration for the creation of the Combitube and Laryngeal Tube.
We will be discussing this in the future, as I am working on a pretty neat simulator of active vomiting during airway management. Email me offline and I will send you the video that demonstrates the system.

And yet, isn’t that how progress is made. Knowing what you “ought” to do according to predefined standards and coming up with another solution that better fits the situation you are dealing with. Good on’ya!

“you ignored the algorithm” I would take as a compliment. I’ve never purposefully intubated the esophagus but when the tube ends up there, I make a point to leave it. fantastic landmark, and if you (gently) re-insert the stylet, you can use the tube to move the glottis into view–think of it as the internal defibrillation of bimanual laryngoscopy.

I think we, in advanced airway training, need to stress how algorithms are greats tools to help us structure our thinking in emergencies but not necessarily law. Algorithms don´t always work and we often need to improvise and think outside the box. That is way harder to teach.

James Du Canto, that mannequin emesis simulator is genius. Regurgitation and soiled airways is one of the things I stress when teaching our juniors about airway management in cardiac arrest. With your simulator I could really challenge them in training scenarios. Please keep me updated!

Reuben, I never thought of that. Ill have a go at your technique next time I´m in theatre. Are there any references for that?

Thanks. I called the technique SALAD (suction assisted laryngoscopy airway decontamination) both as a short description of the technique, and to be somewhat humorous. I could not figure out the way to call it BEEF.

I am planning to create a monograph on how to retrofit mannequins to allow other to reproduce the setup. It may even come to pass that (with some help), I can sell inexpensive Do-It-Yourself conversion kits to adapt the system to the mannequin you already possess. We’d provide the powder to make the vomit too, with instructions. The Laerdal mannequins have defined esophageal tubes to adapt to. Other mannequins may require some work-arounds.

That video was the first full-scale test of this system. The video brings up more questions for me than answers. As we perform more simulations, the answers to the new questions may get answered, and we will begin to define a new line of inquiry in emergency airway management. In the meantime, the students and staff that use the simulator begin to build knowledge, experience, skill and ability to manage the challenging and dangerous occurrence of active vomiting during airway management.

I plan to bring the simulator (or two or three) to SMACC in Chicago, where we can use it practically, examine how different portable suction systems and catheters perform, develop methods to handle the completely soiled airway (double suction setup, suction airway, suction ETT before ventilation, rescue ventilate, suction pharynx again, then change the ETT over bougie for a “clean” ETT) etc…

Well known technique for GI bleeds – stick an ETT in da’ oesophagus and let the blood hose off to your left then pop a clean ETT into the trachea… (thanks to Karel Habig for showing me that technique a year or so back at smacc)

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About ScanCrit

A blog on anaesthesia, intensive care and emergency medicine. In-hospital and outside. Mostly focusing on the critically ill patient. Written by two Scandinavian senior anaesthetic registrars turned consultants.

This is our way of keeping log of articles and interesting things we come across in our work and on the internet. Should any of you out there stumble across this blog and find it useful then all the better.

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